Provider Demographics
NPI:1386916864
Name:SAVIOR OF LIFE THERAPEUTIC RESIDENTIAL GROUP HOME
Entity type:Organization
Organization Name:SAVIOR OF LIFE THERAPEUTIC RESIDENTIAL GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER/FOUNDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:LAMBERT
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:601-454-6419
Mailing Address - Street 1:411 NAPLES RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-5918
Mailing Address - Country:US
Mailing Address - Phone:601-398-2974
Mailing Address - Fax:601-487-6227
Practice Address - Street 1:411 NAPLES RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-5918
Practice Address - Country:US
Practice Address - Phone:601-398-2974
Practice Address - Fax:601-487-6227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-31
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSCYS-SOL-TGH-02322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children